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General NPI Number Information
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NPI Number | 1598175481
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Entity Type | Individual
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Provider Name | DAVID KELLEY SR.
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Gender | Male
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Dates
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Enumeration Date | 05/01/2014
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Last Update Date | 05/01/2014
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Provider Practice Location Address
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Address Line | 4475 24TH AVE.
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City | FORT GRATIOT
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State | MI
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Zip | 48059
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Country | US
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Telephone | 810-385-2164
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Fax | 810-385-2165
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Provider Business Mailing Address
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Address Line | 2949 SHOREWOOD BLVD
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City | FORT GRATIOT
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State | MI
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Zip | 48059-3126
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Country | US
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Telephone | 810-434-9802
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | 5302024206
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License Number State | MI
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